1. PURPOSE
To ensure that anesthesia care provided outside the operating room (NORA) is delivered with the same level of safety, monitoring, staffing, equipment readiness, and rescue capability as operating room anesthesia by establishing standardized requirements for: (1) NORA general safety standards, (2) commissioning/approval of NORA sites, (3) location-specific anesthesia/sedation practices for Endoscopy, Interventional Radiology, Cath Lab, CT, and MRI, (4) transport monitoring to/from NORA and to PACU/ICU, and (5) recovery location selection and requirements, consistent with CBAHI perioperative safety requirements for standardized anesthesia processes and monitoring, and with cited international standards. (istitlaa.ncc.gov.sa)
2. SCOPE
This policy applies to all anesthesia care delivered by anesthesia personnel outside the operating room environment, including (but not limited to): Endoscopy units, Interventional Radiology suites, Cardiac Catheterization laboratories, CT suites, MRI suites, bronchoscopy suites, and other procedural areas formally approved for NORA. It applies to adult and pediatric patients (if pediatric NORA is performed) receiving general anesthesia, MAC, regional techniques with sedation, or sedation/anesthesia administered/managed by anesthesia personnel. (asahq.org)
3. DEFINITIONS
3.1 NORA (Non-Operating Room Anesthesia)
Anesthesia care provided by anesthesia personnel in locations outside the operating room. (asahq.org)
3.2 NORA Site
A physical procedural location (unit/room) commissioned and approved to provide anesthesia care under this policy.
3.3 Commissioning / Site Approval
A formal process verifying a NORA site meets minimum standards for space, gas supply, suction, monitoring, electrical safety, emergency response, staffing, and recovery pathways before services begin and at defined intervals thereafter. (asahq.org)
3.4 Rescue Capability
Ability to recognize deterioration and provide airway and cardiopulmonary rescue (including bag-mask ventilation, advanced airway readiness, defibrillation access, and escalation to rapid response/code and higher level of care). (asahq.org)
3.5 PACU-Equivalent Recovery Area
A recovery area outside the main PACU that meets PACU standards for monitoring, staffing competency, equipment, and discharge processes. (istitlaa.ncc.gov.sa)
3.6 MRI Zones
Controlled access zones used to manage MRI hazards and ensure only MRI-safe equipment/personnel enter the magnet room (Zone IV). (acr.org)
4. POLICY
4.1 General NORA Policy (F1)
- 4.1.1 NORA anesthesia services shall be delivered with safety standards equivalent to those used in the operating room, including appropriate monitoring, equipment, staffing, and emergency readiness. (asahq.org)
- 4.1.2 Anesthesia monitoring in NORA shall meet national requirements and cited international standards, including continuous evaluation of oxygenation, ventilation, circulation, and temperature when clinically indicated/anticipated/suspected. (istitlaa.ncc.gov.sa)
- 4.1.3 NORA anesthesia shall be performed only in sites formally approved through the NORA commissioning process and only by personnel credentialed and privileged for the relevant location and case-mix. (asahq.org)
4.2 NORA Site Approval Checklist Policy (F2)
- 4.2.1 Each NORA site shall be commissioned through a standardized checklist and risk assessment process prior to providing anesthesia services and shall undergo periodic re-approval. (asahq.org)
4.3 Location-Specific Policies (F3–F7)
- 4.3.1 Endoscopy, IR, Cath Lab, CT, and MRI anesthesia/sedation shall follow this general NORA policy plus location-specific requirements defined in Section 5.3–5.7. (asahq.org)
4.4 Transport Monitoring Policy (F8)
- 4.4.1 Patient transport to/from NORA and to PACU/ICU shall be performed with appropriate monitoring and level of care based on patient clinical status and anticipated problems, with a defined transport team capability and documentation from decision to completion. (istitlaa.ncc.gov.sa)
4.5 NORA Recovery Location Policy (F9)
- 4.5.1 Recovery after NORA anesthesia shall occur in the main PACU or an approved PACU-equivalent recovery area; monitoring continues until stable and safely discharged using defined evidence-based criteria. (istitlaa.ncc.gov.sa)
5. PROCEDURES
5.1 F1 — NORA General Policy (Minimum Requirements)
5.1.1 Pre-Service Requirements (Before any anesthetic begins)
- A. Confirm site approval status and availability of required resources for the scheduled case (monitoring, gas/suction, emergency response pathway). (asahq.org)
- B. Conduct a location readiness check prior to patient arrival or prior to induction/sedation start, including:
- Oxygen source(s) and delivery devices appropriate to patient size; adequate supply and backup plan.
- Suction available, functional, and immediately accessible.
- Electrical power availability; emergency power knowledge; safe cable management.
- Lighting adequate for airway management and IV access; ability to darken room if needed without compromising safety.
- Space to position anesthesia equipment, access the patient’s airway, and perform rescue actions (including CPR if needed). (asahq.org)
- C. Communication readiness: working call system and defined escalation contacts (anesthesia backup, rapid response/code blue, PACU/ICU receiving). (istitlaa.ncc.gov.sa)
5.1.2 Space and Environment (Minimum)
- A. The NORA room must provide sufficient space for:
- anesthesia equipment and monitors,
- clear access to the patient’s head/airway,
- the procedural team and equipment, and
- emergency response actions including airway rescue and CPR. (asahq.org)
- B. Patient access limitations (prone positioning, shielding barriers, MRI bore) must be identified pre-case and addressed with a written rescue/evacuation plan where applicable. (asahq.org)
5.1.3 Equipment and Supplies (Minimum Set)
- A. Monitoring equipment (minimum):
- Continuous pulse oximetry
- Non-invasive blood pressure (NIBP) at appropriate intervals
- ECG monitoring as indicated (and available for higher-risk cases)
- Capnography for general anesthesia and when ventilation assessment requires it; for MRI follow ASA MRI advisory monitoring expectations
- Temperature monitoring when clinically significant changes are intended, anticipated, or suspected or as case duration/risk warrants (istitlaa.ncc.gov.sa)
- B. Airway equipment (minimum):
- Bag-valve-mask with appropriate sizes
- Oropharyngeal and nasopharyngeal airways
- Supraglottic airway devices (appropriate sizes)
- Laryngoscopy capability (direct/video as per service design) and ETT supplies
- Suction catheters and oral suction devices
- Emergency airway adjuncts consistent with hospital difficult airway resources (availability on-site or immediate access plan) (asahq.org)
- C. Circulatory support and emergency equipment:
- Defibrillator access and response plan
- IV access supplies, pressure bags, infusion devices (as needed)
- Emergency medications per anesthesia emergency standards
- Ability to deliver oxygen under emergency conditions and during transport (asahq.org)
- D. Medication safety:
- Standardized labeling of syringes/lines
- Secure controlled drug handling (where applicable)
- Readily available rescue medications and reversal agents relevant to planned anesthetic/sedation technique (istitlaa.ncc.gov.sa)
5.1.4 Staffing and Role Requirements
- A. A qualified anesthesia professional shall remain present and responsible throughout anesthesia care in NORA locations consistent with anesthesia monitoring expectations. (istitlaa.ncc.gov.sa)
- B. The procedural team must ensure appropriately trained staff are available to assist with emergency response and patient transfer. (asahq.org)
- C. For high-risk cases or limited-access environments (e.g., MRI), staffing must include sufficient trained personnel to execute the emergency extraction plan and immediate airway rescue in the designated safe zone. (asahq.org)
5.1.5 Clinical Process Standardization in NORA
- A. Apply the same perioperative safety principles used in OR: verification, readiness, monitoring, documentation, and post-procedure handover and recovery criteria. (istitlaa.ncc.gov.sa)
- B. The anesthesia plan must explicitly address NORA constraints: limited space, unfamiliar equipment, patient positioning, access restrictions, remote response times, and transport needs. (Anesthesia Patient Safety Foundation)
5.2 F2 — NORA Site Approval Checklist Policy (Commissioning / Re-Approval)
5.2.1 Commissioning Principles
- A. NORA sites shall not provide anesthesia services until approved through commissioning that verifies minimum requirements and defines site-specific workflows and escalation pathways. (asahq.org)
- B. Commissioning shall involve anesthesia leadership, procedural area leadership, nursing leadership, biomedical engineering, and safety/quality representation as appropriate. (asahq.org)
5.2.2 Commissioning Checklist Domains (Minimum)
- A. Physical environment: room size, lighting, access to head/airway, safe layout, emergency egress. (asahq.org)
- B. Medical gases and suction: oxygen availability, backup cylinder policy, suction functional checks. (asahq.org)
- C. Electrical safety: sufficient outlets, emergency power availability, cable management, equipment safety checks.
- D. Monitoring capability: minimum monitors available and functional; MRI-compatibility when applicable; remote display capability when access is limited. (asahq.org)
- E. Airway and emergency equipment: airway rescue tools, emergency cart/defibrillator access, emergency medication list availability. (asahq.org)
- F. Staffing and training: staff roles defined, competency verified, emergency drills planned, transport team capability defined. (istitlaa.ncc.gov.sa)
- G. Recovery pathway: designated recovery area (PACU or approved local recovery) with monitoring and discharge criteria workflow. (istitlaa.ncc.gov.sa)
- H. Transport pathway: route, elevator access if needed, monitoring during transport, oxygen supply, and handover process. (istitlaa.ncc.gov.sa)
- I. Documentation systems: anesthesia record availability, ability to capture vital signs and events, and secure record storage.
5.2.3 Site Approval Decision and Re-Approval
- A. Approval requires documented sign-off by authorized leadership (Anesthesia + Procedural Area + Safety/Quality). (asahq.org)
- B. Re-approval occurs at least annually or sooner if: equipment changes, room redesign occurs, new procedures/case-mix changes, significant adverse event, or repeated audit failures.
5.2.4 Site-Specific “Stop Rules”
- A. If minimum requirements are not met (oxygen/suction/monitoring failure, inadequate rescue capability, missing trained staff), anesthesia care shall not begin until resolved or the patient is moved to an appropriate location. (asahq.org)
5.3 F3 — Endoscopy Anesthesia/Sedation Policy (EGD/Colonoscopy/ERCP/EUS)
5.3.1 Key Endoscopy Risk Profile (Operational Safety Focus)
- A. Endoscopy often involves shared airway, patient positioning constraints, variable stimulation, and risk of aspiration; therefore airway readiness and suction availability are mandatory and must be checked immediately before sedation/anesthesia. (asahq.org)
- B. Deep sedation or general anesthesia for advanced procedures (ERCP/EUS) requires readiness for rapid escalation to airway control and management of cardiopulmonary events. (asahq.org)
5.3.2 Minimum Requirements for Endoscopy NORA
- A. Room readiness: adequate space at head of bed for airway intervention, suction at bedside, oxygen supply, and immediate access to emergency equipment. (asahq.org)
- B. Monitoring: apply minimum monitoring standards consistent with NORA and anesthesia monitoring requirements; capnography should be used when ventilation cannot be reliably assessed or when deep sedation/general anesthesia is provided. (istitlaa.ncc.gov.sa)
- C. Staffing: anesthesia professional present and responsible; a trained assistant available to help with airway rescue and patient transfer. (asahq.org)
5.3.3 Endoscopy Workflow (Before / During / After)
- A. Pre-procedure: confirm fasting status, aspiration risk, airway risk, and plan for anti-aspiration strategy where indicated; ensure recovery pathway.
- B. During procedure: maintain vigilance for hypoventilation, airway obstruction, laryngospasm, hypotension/bradycardia, and aspiration; document key events and interventions.
- C. Post-procedure: recovery monitoring continues until discharge criteria met; patients with airway events, aspiration concern, or prolonged sedation effect must be escalated to PACU or higher level monitoring per clinical status. (istitlaa.ncc.gov.sa)
5.4 F4 — Interventional Radiology (IR) Anesthesia Policy
5.4.1 IR-Specific Hazards (Operational Safety Focus)
- A. IR cases may be prolonged and require constrained access due to radiation shielding and sterile field; the anesthesia plan must account for limited access and include remote monitoring visibility and rescue positioning. (Anesthesia Patient Safety Foundation)
- B. Risk factors include bleeding, hemodynamic instability, contrast reactions, pain, and need for conversion to general anesthesia or urgent airway control.
5.4.2 Minimum Requirements for IR NORA
- A. Monitoring: minimum anesthesia monitoring standards; consider invasive monitoring based on patient/procedure risk and duration; ensure alarms functional and visible despite shielding barriers. (istitlaa.ncc.gov.sa)
- B. Airway rescue: immediate access to airway equipment and suction; adequate workspace at head for rescue actions.
- C. Emergency response readiness: defined code/rapid response activation and rapid transfer route to PACU/ICU/OR if needed.
5.4.3 IR Workflow Requirements
- A. Pre-procedure: confirm anticoagulation/bleeding risk plan, blood availability if indicated, contrast allergy assessment, and airway risk.
- B. Intra-procedure: maintain normothermia where prolonged exposure occurs; manage fluid balance and hemodynamics; document contrast exposure and reactions if any.
- C. Post-procedure: define recovery destination; high-risk bleeding or airway concern requires PACU/ICU transfer criteria and structured handover.
5.5 F5 — Cardiac Catheterization (Cath Lab) Anesthesia Policy
5.5.1 Cath Lab Risk Profile (Operational Safety Focus)
- A. Cath lab cases can involve rapid hemodynamic changes, arrhythmias, need for pacing/defibrillation, and urgent conversion to higher acuity support; therefore immediate access to defibrillation and hemodynamic support resources is mandatory. (asahq.org)
- B. Patient positioning and sterile field may restrict airway access; the anesthesia plan must anticipate rescue constraints and ensure rapid intervention capability.
5.5.2 Minimum Requirements for Cath Lab NORA
- A. Monitoring: minimum anesthesia monitoring; ECG and BP at appropriate frequency; consider invasive arterial pressure monitoring for high-risk patients/procedures.
- B. Emergency equipment: defibrillator availability and clear responsibility for activation; vasoactive medications immediately available.
- C. Staffing: anesthesia professional present; trained staff available for emergency response and transport.
5.5.3 Cath Lab Workflow
- A. Pre-procedure: verify anticoagulation plan, fasting status, airway risk, baseline hemodynamics, and planned sedation/anesthesia level.
- B. During procedure: communicate continuously with cardiology team about critical procedural steps (balloon inflation, pacing, valve deployment) and hemodynamic vulnerability; document significant events.
- C. Post-procedure: recovery destination (PACU/ICU) determined by hemodynamic stability, airway status, bleeding risk, and required monitoring.
5.6 F6 — CT Anesthesia/Sedation Policy
5.6.1 CT Environment Considerations
- A. CT cases may be brief but have access constraints due to gantry positioning and radiation workflow; planning must ensure continuous monitoring and immediate access for airway rescue. (Anesthesia Patient Safety Foundation)
- B. Pediatric CT frequently requires sedation/anesthesia to minimize movement; dosing, monitoring, and recovery must follow pediatric safeguards when applicable. (asahq.org)
5.6.2 Minimum Requirements for CT NORA
- A. Monitoring and oxygenation/ventilation assessment consistent with NORA standards. (istitlaa.ncc.gov.sa)
- B. Clear emergency plan to stop scan and access patient for rescue.
- C. Transfer/recovery pathway defined prior to sedation/anesthesia start.
5.7 F7 — MRI Anesthesia Policy (MRI Safety, MRI-Compatible Equipment, Emergency Extraction Plan)
5.7.1 Core MRI Safety Standards
- A. MRI anesthesia care shall follow the ASA Practice Advisory for anesthetic care for MRI, including monitoring consistent with ASA basic monitoring and MRI-specific environmental precautions. (asahq.org)
- B. MRI hazards (projectile risk, equipment heating, device interference) require strict MRI safety governance and equipment compatibility; the department shall align MRI processes with the ACR MR Safety framework. (acr.org)
5.7.2 MRI Screening and Preparation
- A. Patient screening: verify implants/devices and MR safety status; document MR conditional requirements and monitoring strategy.
- B. Equipment selection: only MRI-safe or MRI-conditional anesthesia equipment and monitors are permitted in Zone IV; non-MRI-safe equipment must remain outside magnet room (Zones III/II as defined by facility). (acr.org)
- C. Airway strategy: due to restricted access in the scanner bore, the plan must emphasize: secure airway when indicated, prevention of hypoventilation, and immediate rescue feasibility. (asahq.org)
5.7.3 MRI Monitoring Requirements
- A. Monitoring must be consistent with ASA standards and adapted to MRI constraints; remote displays and alarm audibility/visibility must be ensured. (asahq.org)
- B. Continuous oxygenation monitoring is required; ventilation monitoring must be appropriate to anesthetic technique and risk (capnography where applicable/available in MRI-compatible form). (asahq.org)
5.7.4 Emergency Extraction / Evacuation Plan
- A. A written emergency extraction plan shall exist and be rehearsed, defining:
- criteria to abort scan,
- roles for extraction team,
- route from Zone IV to a designated resuscitation zone (commonly Zone III), and
- location of non-MRI-safe emergency equipment used after evacuation. (asahq.org)
- B. In an airway or cardiopulmonary emergency, patient removal from the magnet room to a safer zone for definitive management is a foundational safety principle emphasized in MRI anesthesia safety discussions. (PMC)
5.7.5 Staffing and Training for MRI Anesthesia
- A. Staff assigned to MRI anesthesia must be trained in MRI safety (zone access, equipment labeling, emergency response in MRI). (acr.org)
- B. MRI drills should include airway emergency response and rapid extraction practice consistent with local risk profile. (Anesthesia Patient Safety Foundation)
5.8 F8 — Transport Monitoring Policy (To/From NORA, PACU, ICU)
5.8.1 Transport Governance and Core Requirements
- A. The level of care during transport must be based on patient clinical status and anticipated problems; transport teams shall have policies and procedures directing their practice, and transport documentation begins when the decision is made and continues until completion. (istitlaa.ncc.gov.sa)
- B. Monitoring must not be reduced during transport compared to the level required for the patient’s condition, and appropriate emergency medications and airway equipment must be available. (Anesthesia Patient Safety Foundation)
5.8.2 Minimum Monitoring During Transport (NORA ↔ PACU/ICU/OR)
- A. All patients:
- Pulse oximetry during transport
- Blood pressure monitoring at appropriate intervals
- Continuous clinical assessment of airway patency and ventilation (Anesthesia Patient Safety Foundation)
- B. High-risk/unstable patients or those requiring continuous monitoring:
- ECG monitoring
- Capnography when ventilated with a supraglottic airway/ETT and when clinically indicated for sedated patients, with equipment available per transport risk profile and policy (Anesthesia Patient Safety Foundation)
5.8.3 Transport Equipment and Readiness
- A. Oxygen supply adequate for the entire route plus contingency margin.
- B. Suction immediately available.
- C. Bag-valve-mask and airway adjuncts available; advanced airway readiness for high-risk patients.
- D. Infusions secured; pumps on battery power; spare batteries/charging plan when required.
- E. Clear route planning and receiving unit readiness confirmed before departure. (istitlaa.ncc.gov.sa)
5.8.4 Transport Team Roles
- A. Transport team must be capable of evaluating patient response during transport and initiating rescue steps; for high-risk transports, a provider with airway management and advanced resuscitation competence should accompany the patient. (istitlaa.ncc.gov.sa)
5.8.5 Handover at Arrival
- A. Structured handover at destination (PACU/ICU/ward) includes procedure performed, anesthetic course, airway status, oxygen/ventilation needs, hemodynamics, medications given, complications, and ongoing plan.
5.9 F9 — NORA Recovery Location Policy (PACU vs Local Recovery)
5.9.1 Default Recovery Standard
- A. After NORA anesthesia, patients shall recover in the main PACU unless an alternative recovery area is formally designated and approved as PACU-equivalent. (istitlaa.ncc.gov.sa)
5.9.2 Criteria for PACU-Equivalent Local Recovery Approval
- A. Local recovery may be used only if it meets all of the following:
- Staffing: trained recovery nurse(s) with competency in airway monitoring and escalation.
- Monitoring: continuous oxygenation monitoring and appropriate circulation/ventilation monitoring consistent with patient risk.
- Equipment: oxygen/suction, airway rescue tools, emergency medications, and rapid response activation.
- Documentation: recovery record, reassessment intervals, discharge criteria documentation.
- Escalation pathway: immediate transfer capability to PACU/ICU if deterioration occurs. (istitlaa.ncc.gov.sa)
5.9.3 Discharge and Monitoring Continuation
- A. Monitoring continues during recovery until the patient is stable and safely discharged by a qualified physician using defined evidence-based PACU discharge criteria. (istitlaa.ncc.gov.sa)
5.9.4 High-Risk NORA Recovery Rules
- A. Patients with any of the following should recover in PACU (or ICU if indicated):
- difficult airway course, airway edema risk, or aspiration concern
- significant hemodynamic instability, arrhythmias, major bleeding risk
- high oxygen requirement or ventilation support requirement
- prolonged procedure with residual deep sedation effect
- MRI emergency events or any rescue intervention during NORA (istitlaa.ncc.gov.sa)
6. RESPONSIBILITIES
6.1 Head of Anesthesia / NORA Lead (as designated)
- Ensures NORA governance, site commissioning, re-approval schedule, audit, and corrective actions. (asahq.org)
6.2 Anesthesia Professional
- Confirms site readiness, applies minimum monitoring standards, manages airway rescue readiness, documents anesthesia care, and ensures safe transfer to recovery and destination. (istitlaa.ncc.gov.sa)
6.3 Procedural Area Leadership (Endoscopy/IR/Cath/CT/MRI)
- Ensures environment readiness, local staff competency, emergency response pathways, and compliance with commissioning requirements.
6.4 Biomedical Engineering / Facilities / MRI Safety Roles
- Supports equipment maintenance, safety checks, and MRI equipment compatibility controls, aligned with MR safety governance expectations. (acr.org)
6.5 Nursing and Recovery Staff
- Performs monitoring and documentation during recovery, recognizes deterioration early, and executes escalation protocols.
8. COMPLIANCE AND AUDIT
The anesthesia department shall audit NORA services at defined intervals using indicators such as:
- Site readiness compliance (oxygen/suction/monitor availability; emergency equipment readiness). (asahq.org)
- Monitoring documentation compliance consistent with CBAHI perioperative safety expectations for continuous anesthetic monitoring. (istitlaa.ncc.gov.sa)
- Transport monitoring and documentation compliance per CBAHI patient transfer requirements. (istitlaa.ncc.gov.sa)
- Recovery location appropriateness and discharge criteria documentation compliance. (istitlaa.ncc.gov.sa)
- Adverse events in NORA (airway rescue, unplanned ICU transfer, code activation) with review and corrective action tracking. (Anesthesia Patient Safety Foundation)